Healthcare Provider Details

I. General information

NPI: 1801914031
Provider Name (Legal Business Name): LITO B VILLANUEVA PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2007
Last Update Date: 02/06/2020
Certification Date: 02/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12622 PORTMARNOCK DR
ODESSA FL
33556-5414
US

IV. Provider business mailing address

12622 PORTMARNOCK DR
ODESSA FL
33556-5414
US

V. Phone/Fax

Practice location:
  • Phone: 573-353-0285
  • Fax:
Mailing address:
  • Phone: 573-353-0285
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number02207
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code2251G0304X
TaxonomyGeriatric Physical Therapist
License Number24312
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: